Recommended Treatment for Insomnia in Adults
Cognitive Behavioral Therapy for Insomnia (CBT-I) is the first-line treatment for chronic insomnia in adults with no significant medical history and should be initiated before any pharmacological intervention. 1
Why CBT-I First
The American Academy of Sleep Medicine issues a STRONG recommendation for multicomponent CBT-I based on 49 high-quality randomized controlled trials showing clinically meaningful improvements in remission rates, sleep quality, sleep latency, and wake after sleep onset. 1
CBT-I produces durable long-term benefits that persist well beyond treatment completion, unlike medications which lose effectiveness after discontinuation. 1
Treatment gains from CBT-I are sustained for up to 2 years without need for additional interventions, and sleep often continues to improve after treatment ends. 2, 3
CBT-I carries no risk of tolerance, dependence, or adverse drug effects that are inherent to pharmacological approaches. 4
Core Components of Effective CBT-I
CBT-I must include at least three of the following elements to be considered multicomponent therapy: 1, 5
Sleep restriction therapy: Limits time in bed to match actual sleep duration, creating mild sleep deprivation that strengthens homeostatic sleep drive and consolidates sleep. 5
Stimulus control: Strengthens the association between bed/bedroom and sleep through specific instructions (go to bed only when sleepy, use bed only for sleep and sex, leave bed if unable to sleep within 15-20 minutes). 5
Cognitive therapy: Targets maladaptive thoughts and beliefs about sleep using structured psychoeducation, Socratic questioning, and behavioral experiments. 5
Sleep hygiene education: Addresses environmental and behavioral factors (avoiding caffeine, evening alcohol, late exercise; optimizing sleep environment) but is insufficient as monotherapy. 1, 5
Relaxation techniques: May include progressive muscle relaxation, breathing exercises, or mindfulness-based approaches. 1
Treatment Structure and Delivery
Standard CBT-I is delivered over 4-8 sessions with a trained specialist, using sleep diary data throughout to monitor progress and guide adjustments. 5
Brief Behavioral Therapy for Insomnia (BBT-I) can be offered when resources are limited, delivered in 1-4 sessions emphasizing behavioral components. 6, 5
CBT-I can be effectively delivered through multiple formats: individual therapy (most effective), group sessions, telephone-based programs, web-based modules, or self-help books. 2, 5
Expected Outcomes
Meta-analyses demonstrate the following improvements with CBT-I compared to control conditions: 1, 4
- Sleep onset latency: Reduced by 19 minutes 4
- Wake after sleep onset: Reduced by 26 minutes 4
- Sleep efficiency: Improved by 9.91% 4
- Total sleep time: Improved by 7.6 minutes 4
Temporary Side Effects During Treatment
Early-stage symptoms may include daytime fatigue, sleepiness, mood impairment (irritability), and cognitive difficulties (attention problems). 1
These undesirable effects are primarily restricted to the first 2-3 weeks when behavioral therapies (especially sleep restriction) are introduced and typically resolve by treatment end. 1
When Pharmacotherapy May Be Considered
Medications should only be considered in the following circumstances: 2
- Patient is unable to participate in CBT-I
- Symptoms persist despite adequate trial of CBT-I
- As a temporary adjunct to CBT-I (never as replacement)
First-Line Pharmacological Options (If Needed)
If medication becomes necessary, the American Academy of Sleep Medicine recommends: 6
For sleep onset insomnia:
For sleep maintenance insomnia:
- Eszopiclone 2-3 mg 6
- Temazepam 15 mg 6
- Low-dose doxepin 3-6 mg 6
- Suvorexant (orexin receptor antagonist) 6
For both sleep onset and maintenance:
Critical Medications to Avoid
Over-the-counter antihistamines (diphenhydramine): Not recommended due to lack of efficacy data, daytime sedation, anticholinergic effects, and delirium risk especially in older adults. 6, 2
Trazodone: Explicitly not recommended by the American Academy of Sleep Medicine due to insufficient efficacy data. 6
Herbal supplements and melatonin: Not recommended due to insufficient evidence of efficacy. 6, 2
Long-acting benzodiazepines: Carry increased risks without clear benefit, including falls, cognitive impairment, and dependence. 6
Important Contraindications for Sleep Restriction
Sleep restriction therapy (a component of CBT-I) may be contraindicated in: 1
- Patients working in high-risk occupations (heavy machinery operators, drivers)
- Those predisposed to mania/hypomania
- Patients with poorly controlled seizure disorders
Common Pitfalls to Avoid
Never use sleep hygiene education alone as primary treatment—it is ineffectual as monotherapy and may make patients less receptive to effective behavioral treatments. 1, 5
Never prescribe medications as first-line treatment—this undermines long-term outcomes and creates dependency risk. 5
Never continue pharmacotherapy long-term without periodic reassessment and concurrent behavioral interventions. 6, 2
Never combine multiple sedative medications—this significantly increases risks of falls, cognitive impairment, and complex sleep behaviors. 2
Implementation Algorithm
Initiate CBT-I immediately as first-line treatment for all adults with chronic insomnia 1
Deliver 4-8 sessions with trained specialist, incorporating sleep restriction, stimulus control, cognitive therapy, and sleep hygiene education 5
Monitor progress using sleep diary data throughout treatment 5
If CBT-I insufficient after adequate trial, consider adding short-term pharmacotherapy (benzodiazepine receptor agonists or ramelteon) as temporary adjunct, never as replacement 6, 2
Continue CBT-I even when adding medications, as behavioral interventions provide more sustained effects than medication alone 6
Reassess regularly to evaluate efficacy and monitor for adverse effects, with goal of tapering medications when conditions allow 6